Statin Treatment Risk Groups According to AHA Guidelines
According to the 2013 ACC/AHA guidelines, there are four distinct statin benefit groups for whom statin therapy is recommended to reduce atherosclerotic cardiovascular disease (ASCVD) risk. 1
The Four Statin Benefit Groups:
Individuals with clinical ASCVD (age ≥21 years)
- Includes patients with history of acute coronary syndrome, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of atherosclerotic origin
- Recommendation: High-intensity statin therapy for patients ≤75 years without contraindications; moderate-intensity statin for others
- Goal: ≥50% LDL-C reduction for high-intensity therapy
Individuals with primary elevations of LDL-C ≥190 mg/dL (age ≥21 years)
- Typically represents genetic hypercholesterolemia
- Recommendation: High-intensity statin therapy
- If LDL-C remains ≥100 mg/dL, addition of ezetimibe may be reasonable
Individuals with diabetes mellitus aged 40-75 years with LDL-C 70-189 mg/dL without clinical ASCVD
- Recommendation: Moderate-intensity statin therapy for all; high-intensity statin may be reasonable for those with higher risk (especially age 50-75 years with multiple risk factors)
- Goal: At least 30-49% LDL-C reduction
Individuals without clinical ASCVD or diabetes who are 40-75 years of age with LDL-C 70-189 mg/dL and an estimated 10-year ASCVD risk ≥7.5%
- Risk calculated using the Pooled Cohort Equations
- Recommendation: Moderate to high-intensity statin therapy based on risk discussion
- Requires clinician-patient risk discussion before initiating therapy
Risk Categories for Primary Prevention (2018 Update)
The 2018 update to the guidelines further stratified the primary prevention population (those without ASCVD, diabetes, or LDL-C ≥190 mg/dL) into risk categories 1, 2:
- Low risk: <5% 10-year ASCVD risk
- Borderline risk: 5% to <7.5% 10-year ASCVD risk
- Intermediate risk: 7.5% to <20% 10-year ASCVD risk
- High risk: ≥20% 10-year ASCVD risk
Risk-Enhancing Factors
For borderline or intermediate-risk patients, the following risk-enhancing factors may justify statin initiation 1, 2:
- Family history of premature ASCVD
- Persistently elevated LDL-C ≥160 mg/dL
- Chronic kidney disease
- Metabolic syndrome
- Conditions specific to women (e.g., preeclampsia, premature menopause)
- Inflammatory diseases (e.g., rheumatoid arthritis, psoriasis)
- High-risk ethnicities
- Elevated high-sensitivity C-reactive protein (≥2.0 mg/L)
- Elevated Lipoprotein(a)
- Ankle-brachial index <0.9
Statin Intensity Categories
The guidelines define statin intensity based on expected LDL-C reduction 1, 3:
High-intensity statins: Expected to reduce LDL-C by ≥50%
- Atorvastatin 40-80 mg
- Rosuvastatin 20-40 mg
Moderate-intensity statins: Expected to reduce LDL-C by 30-49%
- Atorvastatin 10-20 mg
- Rosuvastatin 5-10 mg
- Simvastatin 20-40 mg
- Pravastatin 40-80 mg
- Lovastatin 40 mg
- Fluvastatin XL 80 mg
- Pitavastatin 2-4 mg
Low-intensity statins: Expected to reduce LDL-C by <30%
- Simvastatin 10 mg
- Pravastatin 10-20 mg
- Lovastatin 20 mg
- Fluvastatin 20-40 mg
- Pitavastatin 1 mg
Clinical Implementation Considerations
- Lifestyle counseling is the foundation for all statin therapy and should occur at initial and follow-up visits 1
- For primary prevention, a clinician-patient risk discussion is essential before initiating statin therapy 1
- Coronary artery calcium (CAC) scoring may be used in intermediate or selected borderline-risk patients to guide statin decisions 1
- Safety monitoring is important, especially in patients with impaired renal or hepatic function, elderly patients, and those on medications that may interact with statins 1
Treatment Gaps
Despite clear guidelines, significant treatment gaps exist:
- Only 63.7% of ASCVD patients, 61.4% of those with LDL-C ≥190 mg/dL, 43.2% of diabetes patients, and 27.2% of those with 10-year risk ≥7.5% are on statins 4
- Among those on statins, many are not at recommended LDL-C goals 4
The ACC/AHA guidelines represent a shift from LDL-C targets to statin intensity-based treatment, focusing on those most likely to benefit from evidence-based statin therapy to reduce ASCVD morbidity and mortality.